Flat heads and movement preferences in infants

By Kasha Pyka

Have you ever noticed a flat spot on you infant’s head? Or maybe you’ve started to see that they only look or roll to one side? They might even sit with their head tilted to one side – where they look like they’re posing for a cute photoshoot? Any of these attributes may relate to what is known as “torticollis” (i.e. neck muscle tightness) and/or “plagiocephaly” (i.e. flattening of the skull).

What is torticollis and plagiocephaly?

With the onset of the Safe to Sleep Campaign in 1994, the goal was to reduce the risk of Sudden Infant Death Syndrome (SIDS) – commonly known as “crib death”. This campaign advocated for infants to sleep on their backs (which reduced SIDS by 94%) but led to the increase of plagiocephaly from 1 in 300 to 1 in 50 live births. In turn this has increased the number of infants with flat heads leading to more referrals for paediatric physiotherapy treatments. Though the numbers may seem daunting, parents should take comfort in the fact that paediatric physiotherapists see one in two infants with this condition – and simple treatments have been proven to be most effective in the first six months since birth!

Alongside the increase in plagiocephaly, there has been a spike in positional torticollis – i.e. neck tightness due to infants sleeping with their head turned to one side, or favouring moving/rolling to one side. This tightness comes from shortening of the “sternocleidomastoid muscles” – two large muscles on the front of your neck which tip your head to the same side of the muscle and rotate your head to the opposite side of the muscle. As with plagiocephaly, the rise in numbers may concern parents but getting in to see a paediatric physiotherapist within the first four months since birth proves to be very beneficial – with a lot of the therapy being done at home with the helping hands of parents!

What does torticollis and plagiocephaly look like?

If you are querying whether your infant may have torticollis and/or plagiocephaly, watch for these common indicators:

  • Your infant mostly looks to one side;
  • Your infant tilts their head to one side in sitting;
  • Your infant has a flat spot on their head (either on one side, or the entire back of the head); and/or;
  • Your infant has difficulty breastfeeding on one side.

If any of these apply to your infant, contact your family doctor for a referral to a paediatric physiotherapist or self-refer yourself to a child’s treatment centre.

What can I do at home in the meantime?

Since infants sleep so much in the first few months (and do so mainly on their backs), you want to counteract this position by getting lots of tummy time! Not only does this get infants from laying on the back of their heads but it also activates the muscles at the back of the skull which play a role in shaping it (thus reducing plagiocephaly) and stretches the muscles on the front of the neck as well (thus reducing torticollis). The current standard is to get 60 minutes of tummy time per day – which doesn’t need to be done all at once.

You can use these simple strategies to get in the needed amount of tummy time:

  • After a diaper change, roll your infant on to their side and wait to see them initiate bringing their ear to their shoulder instead of picking them up to place them on their tummy (this strengthens and stretches their neck muscles);
  • If you’re relaxing and laying on the couch, place your infant on your chest so they are looking up at you – this not only achieves tummy time but also initiates bonding with your infant!
  • Instead of holding your infant facing you, position your infant facing out. This is considered tummy time since your infant has to extend their neck up and back in order to see – which activates the muscles at the back of their neck.

Other strategies include: positioning your infant so they lay on the side opposite of their flat spot when sleeping, and manually stretching their tight muscles by bringing their opposite ear to their opposite shoulder.

For more targeted strategies and treatments, go see your local paediatric physiotherapist!

How physiotherapy can help your infant

The role of a physiotherapist in the treatment of torticollis and/or plagiocephaly is to correct the position of your infant’s head/neck, as well as ensure proper neck alignment in the future. Specific to torticollis, therapists will stretch out the tight sternocleidomastoid muscles causing the head tilt or positional preference, as well as strengthen the muscles on the opposite side to get their head back into neutral. In terms of plagiocephaly, physiotherapy can help to strengthen the muscles on the back of the skull which aids in shaping your infant’s skull. For either case, a typical session with a physiotherapist would include: education on how to position your infant and different types of holds to stretch out your infant’s neck, as well as hands-on techniques by the therapist.


Kasha PykaKasha Pyka is a 2nd year Physiotherapy student graduating from Queen’s University in August 2017. She has had a number of experiences volunteering in paediatric heath settings (including: SickKids® and Holland Bloorview), as well as recently completing a Physiotherapy placement at Five Counties Children’s Centre – a paediatric out-patient rehabilitation facility. Alongside her clinical experience, Kasha also supports the knowledge translation of other physiotherapy content through her role as the Communication Coordinator for The Movement Centre.